EXHIBIT I - Form 1295 Certificate of Interested Parties.pdf
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- Attached to
- Custom Wheelchair
- Solicitation number
- 2603-001
- Issued by
- Texas
About this file
This file is the Form 1295 Certificate of Interested Parties, a disclosure document required by the Texas Ethics Commission for state and local contract opportunities in Texas. The form serves as a standardized instrument for identifying and disclosing interested parties involved in government contracts, including those providing services, goods, or property to governmental entities and state agencies.
The form requires the filing business entity to provide identification information, including its name, location, and the identification number assigned by the governmental entity tracking the contract. Filers must disclose all interested parties and their nature of interest, categorizing relationships as controlling or intermediary parties. The document must be completed in its entirety with all required sections, including an unsworn declaration executed under penalty of perjury by an authorized agent of the contracting business entity. The form allows for additional pages if necessary to accommodate multiple interested parties and must be filed online through the Texas Ethics Commission website at www.ethics.state.tx.us/File.
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Text version
Form provided by Texas Ethics Commission www.ethics.state.tx.us Revised 12/22/2017
FORM 1295CERTIFICATE OF INTERESTED PARTIES
OFFICE USE ONLOFFICE USE ONLOFFICE USE ONLOFFICE USE ONLOFFICE USE ONLYYYYY
6 UNSWORN DECLARATION
My name is _______________________________________________________, and my date of birth is _______________________________.
My address is ________________________________________________, ___________________, _______, __________, ______________.
(street) (city) (state) (zip code) (country)
I declare under penalty of perjury that the foregoing is true and correct.
Executed in ___________________ County, State of ______________ , on the _______ day of _______________, 20______.
(month) (year)
Signature of authorized agent of contracting business entity (Declarant)
ADD ADDITIONAL PAGES AS NECESSARY
Name of Interested Party Nature of Interest (check applicable)City, State, Country
(place of business) Controlling Intermediary
Name of governmental entity or state agency that is a party to the contract for which the form is being filed.
3 Provide the identification number used by the governmental entity or state agency to track or identify the contract, and provide a description of the services, goods, or other property to be provided under the contract.
Complete Nos. 1 - 4 and 6 if there are interested parties.
Complete Nos. 1, 2, 3, 5, and 6 if there are no interested parties.
1 Name of business entity filing form, and the city, state and country of the business entity's place of business.
Check only if there is NO Interested Party.
Mus t fi le on lin e a t w ww.et hic s.s tat e.t x.u s/F ile
File details come from the government source that posted it. Updated .